Living Will / Advance Directive Template

Living Will / Advance Directive Template

1. Identification of Principal

This Living Will / Advance Directive (“Directive”) is made by:

Full Legal Name: [Full Name]
Date of Birth: [MM/DD/YYYY]
Address: [Street Address, City, State/Province, ZIP/Postal Code, Country]
Phone: [Phone Number]
Email: [Email Address]

2. Statement of Intent

I make this Directive while I am of sound mind and able to make my own decisions.

The purpose of this Directive is to state my wishes about medical treatment and end-of-life care if I become unable to communicate informed decisions for myself. I ask my health care providers, family, and any health care agent named in this document or elsewhere to follow my stated preferences as closely as allowed by applicable law and medical standards.

3. Optional Appointment of Health Care Agent

(If you already have a separate Health Care Power of Attorney or Medical Proxy, you may harmonize this section with that document.)

Primary Health Care Agent:

• Full Legal Name: [Agent Full Name]

• Relationship to Me: [Relationship]

• Address: [Address]

• Phone: [Phone Number]

• Email: [Email Address]

Alternate Health Care Agent (if primary is unable or unwilling to act):

• Full Legal Name: [Alternate Agent Full Name]

• Relationship to Me: [Relationship]

• Address: [Address]

• Phone: [Phone Number]

• Email: [Email Address]

My Health Care Agent should, when allowed by law and consistent with this Directive:

• Communicate with my health care providers;

• Review and consent to or refuse tests, treatments, and procedures;

• Use their best judgment to carry out my expressed wishes and, where not stated, my known values and beliefs.

4. Conditions Under Which This Directive Applies

This Directive applies when both of the following are true (or as otherwise required by local law):

1. I have a serious illness or injury, or I am in a condition such as an advanced terminal illness, permanent unconsciousness, or another state where recovery is very unlikely; and

2. My attending physician and at least one additional qualified health care professional determine that I lack capacity to make or communicate informed medical decisions.

5. General Preferences About Life-Sustaining Treatment

Life-sustaining treatment includes interventions that can prolong life but may not cure the underlying condition (for example, mechanical ventilation, cardiopulmonary resuscitation (CPR), dialysis, or tube feeding).

Select one option by initialing your choice (you may add details in Section 6):

Initials: _______
☐ I want life-sustaining treatment in line with my doctors’ recommendations, including resuscitation, unless treatment is clearly futile or only prolongs the dying process.

Initials: _______
☐ I want life-sustaining treatment only if there is a reasonable chance of recovery to a level of awareness and functioning that I would accept. If my condition is terminal, permanently unconscious, or extremely unlikely to improve to that level, I prefer that life-sustaining treatment be withheld or withdrawn.

Initials: _______
☐ I do not want life-sustaining treatment if I am terminally ill or permanently unconscious and treatment would only prolong the dying process. I prefer comfort-focused care only.

6. Specific Preferences for Certain Treatments

You may state preferences for particular treatments. If you leave a section blank, your health care team and agent (if any) may use their judgment guided by your general wishes.

6.1 Cardiopulmonary Resuscitation (CPR)

In the event my heart stops or I stop breathing:

☐ Attempt CPR and full resuscitation efforts.
☐ Do not attempt CPR (Do Not Resuscitate / DNR preference).

Additional details (if any): [Additional CPR instructions, if any]

6.2 Mechanical Ventilation (Breathing Machines)

If I cannot breathe on my own:

☐ I consent to mechanical ventilation, including intubation, for as long as it offers a reasonable chance of recovery.
☐ I consent to a short trial of mechanical ventilation; if there is no meaningful improvement within [Number] days, I prefer it be withdrawn and comfort care continued.
☐ I do not wish to be placed on mechanical ventilation if recovery to an acceptable quality of life is unlikely.

Additional details (if any): [Additional ventilation instructions, if any]

6.3 Artificial Nutrition and Hydration (Feeding Tubes / IV Fluids)

If I cannot eat or drink safely on my own:

☐ I consent to artificial nutrition and hydration (such as feeding tubes or IV fluids) as recommended by my doctors.
☐ I consent to short-term artificial nutrition and hydration for rehabilitation or recovery attempts, but not long-term when there is little chance of improvement.
☐ I do not wish to receive artificial nutrition and hydration if I am terminally ill or permanently unconscious and it would only prolong the dying process, but I want regular mouth care and comfort measures.

Additional details (if any): [Additional nutrition/hydration instructions, if any]

6.4 Dialysis

If my kidneys fail or I require dialysis:

☐ I consent to dialysis as recommended while there is a reasonable chance of recovery or stable quality of life.
☐ I consent to a time-limited trial of dialysis; if there is no meaningful improvement within [Number] weeks, I prefer it be stopped.
☐ I do not wish to receive dialysis if I am terminally ill or permanently unconscious and it will not meaningfully improve my condition.

Additional details (if any): [Additional dialysis instructions, if any]

7. Pain Relief and Comfort Care

Regardless of the choices above, I wish to receive appropriate care aimed at relieving pain and discomfort.

☐ I want medications and other measures to relieve pain and distress, even if they may unintentionally shorten my life, as long as they are given to relieve suffering and not to cause death.

Comfort care preferences (optional):

• Preferred setting for end-of-life care (if possible): [Home / Hospital / Hospice facility / Other]

• Other comfort or personal care wishes: [Comfort care wishes, including music, visitors, spiritual support, etc.]

8. Organ and Tissue Donation

After my death, and as permitted by local law, I state my wishes about organ and tissue donation:

☐ I am willing to donate any needed organs and tissues for transplant, research, or education.
☐ I am willing to donate only the following: [Specific organs/tissues or purposes].
☐ I do not wish to be an organ or tissue donor.

Any additional preferences: [Additional organ donation instructions, if any]

9. Pregnancy (If Applicable)

(Complete if relevant and recognized under local law.)

If I am pregnant at the time this Directive would otherwise take effect, my preferences are:

☐ I want my medical team to consider the health and viability of the fetus and follow applicable law in making decisions about life-sustaining treatment.
☐ Additional pregnancy-related instructions: [Additional pregnancy-related instructions, if any]

10. Other Wishes, Values, or Religious/Spiritual Considerations

You may include any other guidance important to you, such as religious, cultural, or personal beliefs that you want considered in your care.

[Other wishes, values, or religious / spiritual considerations]

11. Revocation of Prior Directives

By signing this Directive, I revoke any prior living will, advance directive, or similar document that I have signed before this date, to the extent allowed by law, unless I expressly state here that a prior document remains in effect for a specific purpose:

Status of prior directives: [“All prior directives are revoked” or description of any that remain in force]

12. Signature of Principal

I sign this Living Will / Advance Directive voluntarily and understand its contents.

Principal Signature: _______________________________
Principal Printed Name: [Full Name]
Date: [MM/DD/YYYY]

13. Witness Statements and Signatures

(Adapt this section to meet local witnessing requirements. Witnesses should generally be adults who are not the Agent, not directly responsible for your medical care, and not major beneficiaries under your will or insurance, if possible.)

Witness 1

I declare that:

• I am at least 18 years old (or the age of majority in this jurisdiction);

• I am not the Principal’s named Health Care Agent in this document;

• To the best of my knowledge, the Principal is of sound mind and signed this Directive willingly.

Witness 1 Signature: _______________________________
Witness 1 Printed Name: [Full Name]
Address: [Address]
Date: [MM/DD/YYYY]

Witness 2

I declare that:

• I am at least 18 years old (or the age of majority in this jurisdiction);

• I am not the Principal’s named Health Care Agent in this document;

• To the best of my knowledge, the Principal is of sound mind and signed this Directive willingly.

Witness 2 Signature: _______________________________
Witness 2 Printed Name: [Full Name]
Address: [Address]
Date: [MM/DD/YYYY]

14. Notary Acknowledgment (If Required or Desired)

(Modify this notary block to match the wording required where the document is signed.)

State/Province of: [State/Province]
County of: [County]

On this _____ day of __________, 20, before me, the undersigned notary public, personally appeared [Principal Full Name], known to me or satisfactorily proven to be the person whose name is signed to this Living Will / Advance Directive, and acknowledged that they executed it for the purposes stated in it.

Notary Public Signature: _______________________________
Notary Printed Name: [Notary Name]
My Commission Expires: [Date]
Notary Seal (if applicable): [Seal]